Strategies for Treating PTSD

In the course of our careers, many of us have run
across terms like shell shock, soldier's heart, combat neurosis, combat
fatigue, or—get this—Da Costa syndrome, known for more than a century as
neurocirculatory asthenia, and a favorite term that my father, an
ophthalmic surgeon, used for
patients he thought had visual difficulties that were secondary to
severe emotional stress.

Historically, these syndromes appear to be
labels for severe emotional
responses to life.

As you know, such psychological stress leads to
recurrent thoughts, nightmares, and flashbacks to the dreaded event. The
patient may avoid people and places, and interpersonal relationships
may deteriorate. Insomnia, irritability, emotional detachment, anger,
and concentration difficulties may occur.

That collection of stress reactions—named
posttraumatic stress disorder (PTSD)
in 1980 by the American Psychiatric Association—also leads to increased
heart rates and hyperactivity of the sympathetic nervous system (Biol.
Psychiatry 1997;41:319-26). Furthermore, models of neuroimaging
techniques have shown smaller hippocampal volume in patients who have
chronic, severe PTSD
(Psychiatric Annals 2004;34:845-56).

With the recognition of PTSD as a disorder in the DSM-III,
the many symptoms of acute stress reactions secondary to
life-threatening situations began to be codified, organized, and better
understood.

Such recognition is often an important first
step to better treatment. Not only is the clearly evident PTSD seen, but the subtle, less
intense variations become obvious and, indeed, treatable.

The results of PTSD can be devastating. In the
United States, 1%-3% of the population is affected by PTSD; at the subclinical level,
5%-15% of the population is affected. Among Vietnam veterans, 30% of the
soldiers were affected, and an additional 25% were affected at the
subclinical level (“Concise Textbook of Clinical Psychiatry” [Baltimore:
Williams and Wilkins, 1996, p. 211]). Clearly, PTSD is one of the most commonly
seen psychiatric disorders.

Treatments for
the disorder abound, although their rates of success appear to vary.
Medications, cognitive-behavioral therapy (CBT), group therapy,
traditional behavioral therapy, and hypnosis are used. In my experience
with PTSD, I have found that
a place exists for most of
these treatments.

The medications, of course, are critical—not so
much for the PTSD itself as for the severe, life-threatening
depressions that can coexist with this disorder.

I've treated several PTSD patients using CBT as well as
behavior modification and hypnosis. My approach is to evaluate for depression and, if it is
present, to treat it as soon as possible. Relief of the symptoms and
thoughts of depression sometimes leads to control of the PTSD and to its subsequent
remission. In other cases, my preferred treatment has been a combination
of hypnosis and behavior modification.

I was able to get the best results combining the
two approaches. For other
clinicians, CBT alone or in groups may work better. In vivo treatments
have been effective but are time-consuming. Newer techniques—such as eye
movement desensitization reprocessing (EMDR) or virtual reality
techniques—are now being used. The data on those approaches are not yet
in, but they hold great promise.

I have successfully treated PTSD many times over the years,
but two cases stand out. One involved a woman who was attacked by a dog
while walking home from work one winter day. She was bitten on both arms
and, in her effort to escape, she slipped on ice and shattered her left
patella. The patient was hospitalized; she had to undergo a partial
knee replacement and a subsequent referral to rehabilitation medicine.
The referral came to me through her orthopedic surgeon.

The second case involved a father whose
8-year-old son had been playing at a friend's house and was being
dropped off in a school parking lot where the father waited to pick him
up. As the father watched, the boy began to exit the back door of the
friend's car, catching his coat in the door. The oblivious driver took
off, dragging the boy about 200 feet with the father chasing the car on
foot. The boy luckily suffered only bruises and contusions.

The dog-bite victim and the helpless father
experienced similar psychological and physical stresses. The father
experienced guilt, thinking that he should have either picked up his son
at the friend's home or been closer to the friend's car. The woman—who
never liked animals—thought that she should have crossed the street when
she saw the dog and its owner approaching.

In an objective sense, the woman's trauma was
more intense than that of the father. But in terms of subjective
perceptions, each suffered PTSD.

For
each patient, I used my Learning, Philosophy, and Action (LPA)
technique. One visit was used to help the patient understand PTSD. The second visit was used to
reach a global philosophical understanding, based on patient history,
of what might have precipitated such an emotional response. In both
patients' cases, the events were of such magnitude that the
philosophical model was hardly necessary. But such exploration is
important.

The action phase introduced ways to alleviate
the disorder. The father was seen 2 days after the trauma, and the woman
3 months after the event, but I used the same technique with both
patients. First, I taught the patient self-hypnosis, which took about 30
minutes. Then, I used an in vitro combination of systematic
desensitization and reciprocal inhibition processes based on a
split-screen movie technique.

While the patient was relaxed—and using hypnosis
to achieve this—I introduced the concept of a large movie screen. As
the patient visualized the screen, I asked him or her to imagine a
thick, black line down the screen's center. On the left side of the
line, I asked the patient to project the events leading up to the
traumatic exposure, such as walking down the street or waiting for the son. On the right side of
the screen, I asked the patient to visualize the expected happy ending,
such as arriving home safely in the woman's case, or safely picking up
the son in the father's case. The split-screen approach allows the
patient to look from left to right and from right to left on the screen,
an important part of the desensitization/inhibition process's next
step.

As the process moves forward, the patient gets
to see the traumatic event on the left side of the screen—not the real
event, but a review of it. By doing this, the event gets out of the
patient and onto the screen. The patient sees it, but does not
reexperience the event. This is therapeutic.

We then move to the right side of the screen and
use it to imagine any pleasant experience that the patient wishes. We
link the two images. The traumatic events are linked to perceived
pleasure. This desensitization/reciprocal inhibition process did negate
the PTSD in both patients.

After three visits, the father was just fine 6
months later. The woman went on for
about 3 months with a combination of learning and desensitization.
About 70% of her PTSD
problem was resolved.

She opted to continue in traditional talk
psychotherapy. She was fine 1 year later, and treatment ended. Follow-up
after 1 year was good.

Dealing with PTSD is challenging, and we need
to be ready with the proper treatments. It is up to us to recognize this
disorder and identify the treatment that works best for each patient.